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Department of Defense form 2642. Official designation: TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT. Purpose: CHAMPUS Claim Patient's Request for Medical Payment. Current edition not stated, status not stated.
Prescribing authority: not stated. Proponent: not stated. Unlike service-specific publications, DD forms carry Department-level authority and apply across the Army, Navy, Air Force, Marine Corps, Space Force and Coast Guard when operating under Defense jurisdiction.
Users include uniformed members of any branch, DoD civilian employees, contractor personnel where authorized, and the administrative staff who process the completed record.
Submission follows the schedule set by not stated and by local implementing procedures. This page provides the blank form for download and general orientation only.
Formats offered: PDF. Length: 1 pages. Fillable field count: roughly 100.
Pdf serves as the base format. In the fillable variant, each box is an interactive field that holds typed text inside the document. In the flat printable variant, no fields exist — the page prints as a blank to be completed by hand. Typed entries survive transmission; handwriting does not always survive scanning.
What the form asks for
- Address
- Block12A
- CheckBox1
- CheckBox2
- CheckBox3
- CheckBox4
- CheckBox5
- CheckBox6
- CheckBox7
- CheckLeft
- CheckRight
- Checks
- ContentArea
- CurrentPage
- DateField
- DateField1
- Draft
- FifthRow
- FirstRow
- Footer
- FormNumber_Date
- FourthRow
- Frame
- Ins1
Completion runs in the order printed on the page: identifying data at the head, the body of the entry next, certification at the foot. Header data frequently governs what belongs in the fields below it.
The current edition is not stated. Superseded editions of DD forms are frequently rejected at the receiving office, since Department-wide forms change centrally and older layouts lose their field correspondence. Edition date appears in the lower corner of the printed blank.
Instructions printed on the form or in not stated govern individual field entries. Where the two differ, the governing publication controls.
The completed document moves to the office named in not stated or in local guidance. A retained copy is conventional practice.
Cross-referenced forms are found through the numbering system. The DD sequence is Department-level and unified, which means a number cited on the page identifies one document across the whole Department.
Some procedures pair a DD form with a service form. The two numbering systems are separate — service forms answer to a service proponent, DD forms to not stated or another Department office — and a matching number in each system means nothing.
Editions change because the underlying directive changes, because collection requirements are revised, or because Privacy Act language is updated. Checking the edition date at the point of download is the practical response.
This page distributes a published Department of Defense document and describes it. It is not a source of legal advice and makes no representation about acceptance of any completed form. Questions of applicability, eligibility or procedure belong to not stated, the servicing personnel office, or the office named in not stated.
Questions and answers
- What is DD Form 2642?
- TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT
- Which edition is current?
- Not stated by the publisher
- Who is responsible for this form?
- Not stated
- In which formats can it be downloaded?